Bartholin Gland Cyst

Etiology

A Bartholin gland cyst is a benign blockage of the Bartholin gland that is usually unilateral, asymptomatic, and may be incidentally found during a pelvic exam or imaging study. Bartholin gland obstruction may occur after trauma to the area, episiotomy, or childbirth; however, it usually occurs without an identifiable cause.[5] One causative theory is that ductal obstruction is due to friction during sexual intercourse.[1] Bartholin cyst formation is the most common complication after surgical treatment for provoked vulvodynia, including procedures, eg, perineoplasty, vestibuloplasty, and various forms of vestibulectomy (eg, simplified, modified, posterior, or radical), with an incidence of up to 9%.[6]

Epidemiology

Bartholin cysts and abscesses most commonly occur in individuals of childbearing age. Symptomatic cases account for about 2% of all gynecologic visits each year. An abscess can develop without a preceding cyst, and abscesses are approximately 3 times more common than cysts. A cyst does not always precede an abscess.[7][8] Bartholin gland carcinoma is extremely rare and accounts for less than 2% of vulvar cancers, usually diagnosed after menopause.[2] 

Pathophysiology

A Bartholin cyst forms when the duct of the Bartholin gland becomes obstructed, preventing normal drainage of glandular secretions. This leads to fluid accumulation. A Bartholin cyst is usually 2 to 4 cm in diameter and may cause dyspareunia, urinary irritation, and vague pelvic pain or pressure. When bacteria enter the blocked duct, the cyst can become infected, forming an abscess. These abscesses are usually polymicrobial, containing normal vaginal and cervical flora, eg, Staphylococcus, Streptococcus, and Escherichia coli.[8]

History and Physical

When taking a history from a patient with a suspected Bartholin gland cyst or abscess, clinicians should inquire about the duration of symptoms, tenderness with activities, eg, walking, sitting, standing, or sexual intercourse, presence of purulent drainage, a history of previous Bartholin gland cyst or abscess, vaginal bleeding or discharge, and sexually transmitted infections. 

The physical exam will often reveal asymmetry with a protrusion of 1 side (left or right) of the inferior aspect of the vulva and vagina. Bartholin gland abscesses, unlike Bartholin cysts, are very painful. While both are primarily unilateral, Bartholin abscesses are often tender to palpation, erythematous, indurated, and may have an area of fluctuance or purulent drainage.[8] Bartholin cysts frequently have a prolonged course, as they are typically asymptomatic. Malignancy, while rare, may have a similar presentation and is most commonly a squamous cell carcinoma.[2]

Evaluation

Bartholin cysts and abscesses do not frequently require further laboratory or radiographic studies; however, wound cultures and biopsy may be performed during incision and drainage of an abscess. If sexually transmitted infections are suspected, then a full sexually transmitted infection screen should be considered and appropriate treatment initiated. 

If malignancy is suspected due to an atypical presentation of the mass or if the patient is older than 40, then a biopsy should be considered.[9] In 1897, diagnostic criteria were developed for Bartholin gland cancer. They were later revised by Chamlian and Taylor in 1972 and include the following 3 criteria

• The lesion involves the area of the Bartholin gland and is histologically compatible with the origin from the organ.
• Pathological examination shows transition areas from normal to neoplastic elements.
• No evidence of other primary tumors as an etiology of the malignancy is noted.[2]

Treatment / Management

The size of the cyst, the patient´s age, and history of recurrence are all factored in to determine the appropriate management of a Bartholin cyst. Asymptomatic Bartholin cysts do not require treatment. Bartholin cysts or abscesses that are spontaneously draining may be managed conservatively with sitz baths and analgesics. With incision and drainage only, high recurrence rates are unacceptably high. Therefore, this is not recommended for treatment.[10]

No one method of treatment is superior to any other in terms of recurrence rates.[11] First-time Bartholin abscesses or symptomatic cysts may be treated with incision and drainage with Word catheter placement due to the ease and effectiveness of this treatment. The Word catheter, first introduced in 1968, is commonly used in the United States and Europe to treat symptomatic Bartholin cysts or abscesses. Word catheters are a small, 5.5 cm silicone tube with an inflatable balloon on the end. The catheter is placed into the cyst or abscess to allow continued drainage and help form a new duct, reducing the need for surgery. The procedure is simple, quick, and can be done in an office setting. In Germany, the usual treatment is marsupialization, typically done under general anesthesia, as the use of the Word catheter is uncommon and not widely practiced.[1](A1)

Catheter Drainage Therapy

Incision and drainage with a Word catheter are performed by first cleaning the region with povidone-iodine and anesthetizing the location where the incision will be made with at least 3 mL of 1% lidocaine. A small, approximately 3 to 5 mm, vertical stab incision should be made with a #11 scalpel along the mucosal surface of the labia minora to avoid noticeable scarring and to reduce the risk of Word catheter displacement (see Image. Bartholin Gland Word Catheter). Purulent discharge evacuated may be sent to the lab for cultures, and a biopsy may also be performed at this time. The Word catheter is then inserted with the balloon tip sitting within the abscess cavity. The balloon tip is inflated with 3 to 5 mL of saline. For comfort and to reduce the chance of displacement, the external portion of the Word catheter is tucked into the vagina. Word catheters should be left in place for at least 4 weeks for appropriate drainage and tract epithelialization.[12] Patients do not need to follow any activity restrictions, including sexual activity. 

Placing a Word catheter can present challenges. A small incision may make insertion difficult, while a larger incision increases the risk of the catheter dislodging prematurely. Additionally, patients may experience discomfort if the catheter balloon is inflated excessively.[13]

A similar procedure may be used to treat a symptomatic Bartholin cyst or abscess, especially in resource-poor settings. This involves the use of a Jacobi ring, a ring made from butterfly needle tubing and suture. The tubing is threaded with an approximately 20-cm length of 2-0 silk suture. The Jacobi ring enters and exits the abscess through 2 separate incisions. When the suture ends are tied, a closed rubber ring is formed.[13] In this technique, a small incision is made on the mucosal surface of the abscess to allow lysis of adhesions and drainage. A Kelly forceps is then inserted into the cavity, where a second small incision is created. The forceps are used to thread one end of the Jacobi ring, a 5-cm segment of butterfly venipuncture tubing, through the abscess or cyst cavity. An absorbable suture previously placed within the lumen is tied at both ends to form a loop or ring. Unlike balloon catheters, this method has a lower risk of early dislodgment and better patient satisfaction. The tube can remain in place for 4 to 6 weeks. Removal is simple and involves cutting the suture and withdrawing the tubing.

Surgical Therapies

Incision and drainage with Word catheter or Jacobi ring placement may be attempted a second time for recurrent Bartholin cysts. Antibiotic therapy should be considered for those who have failed initial incision and drainage with a Word catheter placement, patients with systemic symptoms including fever, patients who have suspected sepsis, and those considered at high risk for recurrence.

Marsupialization is generally used for recurrent cases and is usually performed by a gynecologist in the operating room.[10] Marsupialization is performed by creating a 2-cm incision lateral to the hymenal ring, everting the edges with forceps, and suturing the edges onto the epithelial surface with interrupted absorbable sutures.[14] Treatment with marsupialization is 7 times more costly than treatment with a Word catheter.[14] Other less common procedures include silver nitrate or alcohol sclerotherapy [15][10], carbon dioxide laser vaporization [16], Jacobi ring placement [17], and Bartholin gland excision as a last resort when other modalities have failed.(A1)

Pregnant Patients

Women who are pregnant and have Bartholin abscesses should be treated in the same manner as nonpregnant women, except Bartholin gland excision, which should be avoided if possible due to the increased risk of bleeding.

Differential Diagnosis

Most benign vaginal cysts are embryological remnants or the result of trauma. The Müllerian ducts develop into the fallopian tubes, uterus, cervix, broad ligament, and upper vagina. Normally, the vaginal lining changes to squamous epithelium from the urogenital sinus. However, some Müllerian epithelium may remain along the vaginal wall. As a result, Müllerian cysts can form anywhere in the vagina.[18]

Differential diagnoses of Bartholin cyst include:

• Other cysts (eg, inclusion, Müllerian, or Gartner, Skene, sebaceous, and canal of Nuck)
• Vaginal prolapse
• Vulvar angiomyofibroblastoma
• Endometriosis
• Epidermal inclusion cyst
• Choriocarcinoma
• Myeloid sarcoma
• Leiomyoma
• Myxoid leiomyosarcoma
• Fibroma
• Angiomyxoma
• Adenosis
• Hematoma
• Myoblastoma
• Ischiorectal abscess
• Folliculitis
• Fibroadenoma
• Lipoma
• Papillary hidradenoma
• Syringoma
• Urethral diverticulum
• Adenocarcinoma
• Squamous cell carcinoma

Pertinent Studies and Ongoing Trials

In the WoMan-trial (World Catheter and Marsupialization in Women With a Cyst or Abscess of the Bartholin Gland), a randomized controlled trial in the Netherlands and England between August 2010 and May 2014, 161 women were randomly allocated to treatment by Word catheter or marsupialization to compare the recurrence of a cyst or abscess within 1 year. Recurrence occurred in 10 women (12%) in the Word catheter group and 8 women (10%) in the marsupialization group. Within the first 24 hours after treatment, 33% used analgesics in the Word catheter group versus 74% in the marsupialization group. Time from diagnosis to treatment was 1 hour for placement of Word catheter versus 4 hours for marsupialization. Recurrence rates were found to be comparable within the 2 groups; however, the marsupialization group had increased use of analgesics within the first 24 hours and also had increased duration of treatment.[11]

Treatment Planning

Imaging may be helpful when evaluating a vaginal cyst, and it may help in planning surgical excision, particularly when the etiology or presentation is unclear.[18]

Toxicity and Adverse Effect Management

Placement of the Word catheter is generally described as a painful procedure. But, the catheter is well tolerated thereafter with few adverse effects, including interference with the patient’s sexual activity.[1]

Prognosis

The prognosis of a Bartholin cyst is excellent, but if the cyst is just aspirated, high recurrence rates have been reported. The healing and recurrence rates are similar among fistulization with Word catheter, marsupialization, and silver nitrate and alcohol sclerotherapy. Needle aspiration and incision and drainage, the 2 simplest procedures, are not recommended due to their relatively increased recurrence rate.[19]

Complications

The treatment of Bartholin gland cysts by traditional surgery is characterized by some disadvantages and complications, eg, hemorrhage, postoperative dyspareunia, infections, and the necessity for general anesthesia. CO₂ laser surgery may be less invasive.[20]